The document discusses a case of a 28-year-old woman diagnosed with acute transverse myelitis, characterized by weakness, sensory changes, and MRI findings. It outlines the evaluation and treatment approach, emphasizing the need for hospitalization, high-dose corticosteroids as the first-line therapy, and supportive care. It also highlights the importance of thorough diagnostic assessment to identify potential underlying causes and provide appropriate counseling for patients and families.

1. Clinical Practice
Transverse Myelitis
Elliot M. Frohman, M.D., Ph.D., and Dean M. Wingerchuk, M.D.
N Engl J Med
Volume 363(6):564-572
August 5, 2010

2. Case Vignette
• An otherwise healthy 28-year-old woman presents to the emergency
department with progressive weakness that began 3 days earlier.
• She reports difficulty walking, numbness in the body below her breasts,
and urinary urgency, and she notes that neck flexion triggers an
electrical sensation that radiates to the coccyx.
• Physical examination reveals moderate paraparesis with hyperreflexia, a
left extensor plantar response, impairment of vibratory and
proprioceptive sensation, and a sensory level at T6.
• Magnetic resonance imaging (MRI) reveals a lower cervical cord lesion
that enhances after gadolinium administration, a finding that is
consistent with transverse myelitis.
• How should she be further evaluated and treated?

3. Diagnostic Algorithm for the Evaluation of Acute Myelopathies and Myelitis
Frohman EM, Wingerchuk DM. N Engl J Med 2010;363:564-
572

4. Features of Common Myelitis Syndromes on Neuroimaging
Frohman EM, Wingerchuk DM. N Engl J Med 2010;363:564-572

5. Diagnostic Criteria for Transverse Myelitis
Frohman EM, Wingerchuk DM. N Engl J Med 2010;363:564-572

6. Concise Differential Diagnosis and Diagnostic Testing for Transverse Myelitis
Frohman EM, Wingerchuk DM. N Engl J Med 2010;363:564-572

7. Conclusions and Recommendations
• The patient described in the vignette presented with classic clinical and neuroimaging
manifestations of acute transverse myelitis.
• Information obtained from the clinical history, an analysis of the cerebrospinal fluid, the
results of other laboratory tests, and an MRI study of the brain, together with an
assessment of the characteristics of the spinal cord lesion, allow for a rapid
assessment of the likelihood that the episode of transverse myelitis is associated with
an infection, an underlying systemic disease, or a demyelinating disease such as
multiple sclerosis.
• Admission to the hospital is warranted for observation of the evolution of the syndrome
and for treatment of the patient.
• Data from randomized trials to inform the treatment specifically for patients with
transverse myelitis are lacking; however, on the basis of clinical experience and trials
involving patients with other demyelinating diseases, high-dose corticosteroids are
considered to be the first-line therapy.
• Assessments by physical and occupational therapists and treatment of symptoms such
as pain and urinary dysfunction are indicated.
• Counseling about the natural history of transverse myelitis and the prognosis must be
given on an individual basis, depending on the cause of the condition (if it is identified),
and patients and families should be offered support in managing this debilitating
condition.